MEDICARE: DR. DARLENE DAVIS GOODWINE LP, LCADC, CAADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6301018149	MI
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	276214	KY
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	1135	KY
4	101YA0400X	Addiction (Substance Use Disorder) Counselor	C-03369	MI
5	103TC0700X	Clinical Psychologist	P.08296	OH
6	103TC0700X	Clinical Psychologist	6301018149	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649576612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARLENE DAVIS GOODWINE LP, LCADC, CAADC

Provider Business Mailing Address
First Line	:	1030 BURLINGTON LN STE 5
Second Line	:
City	:	FRANKFORT
State	:	KY
Zip	:	40601-8444
Country	:	US
Telephone Number	:	502-276-5096
Fax Number	:

Provider Business Practice Location Address
First Line	:	4710 W SAGINAW HWY STE 9
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48917-2654
Country	:	US
Telephone Number	:	517-305-0641
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2011
Last Update Date	:	06/09/2022

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